Unveiling the language of scars: A patient-centric themed framework for comprehensive scar morphology.

BACKGROUND: Scarring, a pervasive issue spanning across medical disciplines, lacks a comprehensive terminology for effective communication, patient engagement, and outcome assessment. Existing scar classification systems are constrained by specific pathologies, physician-centric features, and inadequately account for emerging technologies. This study refrains from proposing yet another classification system and instead revisits the foundational language of scar morphology through a theme analysis of primary patient complaints. METHOD: Data encompassing five years of a high-volume scar practice was analysed. Primary complaints were aggregated into collective descriptors and further organized into theme domains. The resulting hierarchical map of presenting complaints revealed five key domains: Loss of Function, Contour, Texture, Vector, and Colour Presenting complaints were codified into 42 items, which were then categorised into 14 collective descriptor terms. The latter were in turn organised into five overarching themes. RESULT: Loss of Function, accounting for 10% of primary concerns, signifies reduced function attributed solely to the scar. Contour, encompassing 41% of concerns, pertains to scar height, shape, and depth. Texture, representing 12% of concerns, denotes tactile variations such as hardness, roughness, and moisture. Vector, comprising 13% of concerns, refers to scar tissue tension and associated distortions. Colour, the concern in 24% of cases, encompasses variations in pigmentation, vascularity, and exogenous pigments. DISCUSSION: Standardized terminology enhances patient care, communication, and research. This study underscores the fundamental question of "what bothers the patient," reviving a patient-centred approach to scar management. By prioritizing themes based on patient complaints, this study innovatively integrates function, aesthetics, and patient experience. In conclusion, this study pioneers a paradigm shift in scar management by presenting a patient-driven theme framework that offers a common language for healthcare professionals and patients. Embracing this language harmonizes scar treatment, fosters innovation, and transforms scars from silent reminders into stories of resilience and healing.

Extrapolating novel techniques utilised in solid organ transplantation to the microsurgical and vascularised composite allograft arena.

Ischemia reperfusion injury (IRI) is characterised initially by restriction of oxygenated blood flow to an organ bed, resulting in tissue hypoxia and ischaemic injury, followed by further 'reperfusion' injury upon restoration of perfusion, with an influx of oxygen, inflammatory cells and generation of free radicals. The culmination is a complex interplay between cellular and biochemical processes involved in inflammation and coagulation, exhibited as the 'no re-flow' phenomenon. Under ideal circumstances, autologous free tissue transfer is performed with short ischemic times. However, there are certain clinical scenarios where the ischaemic period can be prolonged due to technical and non-technical factors. IRI is inevitable and can be possibly more pronounced in such cases. In these cases, there may be a role for plastic surgeons to adopt some of the anti-ischaemia reperfusion injury (IRI) practices used in solid organ transplantation (SOT). Knowledge of the current trends in SOT IRI reduction should be discussed by plastic surgeons to assess whether certain facets can be extrapolated into the plastic and reconstructive armamentarium. These can be applicable to more challenging microsurgical cases, including composite free tissue transfer. Three important aspects are discussed further in this editorial: (1) cold flushing, (2) machine perfusion and pharmacological manipulation. Ongoing research will need to study the impact these potential interventions will have on the acute complications but also in which subset of patients they would be most beneficial. This area is novel and exciting but cautious implementation is advised with careful scrutiny of future data.

How Educational Theory Can Inform the Training and Practice of Plastic Surgeons.

It is important to optimize our current learning and teaching models, particularly in a climate of decreased clinical exposure. With technical advancements and clinical care now more accountable, traditional methods of skill acquisition need to be revisited. The past decade has seen changes in plastic surgery curricula. There has also been a shift toward competency-based training programs reflecting the growing emphasis on outcomes-based surgical education. This review explores the role of educational theory in promoting effective learning in practical skills teaching. Key models of educational theory are presented and their application to plastic surgery training to an expert level are highlighted. These models include (1) learning within communities of practice (Lave and Wenger's theory); (2) the role of the zone of proximal development and importance of the availability of expert assistance (Vygotsky's theory); (3) skill acquisition and retention (Dreyfus' and Dreyfus', and Fitts' and Posner's theories); (4) development of expertise after repeated practice and regular reinforcement (Ericsson's theory); and (5) the assessment of competence (Miller's triangle). Future plastic surgeons need to possess a thorough understanding of the technical and nontechnical skills required to manage patients effectively. Surgical educators are therefore compelled to develop practical training programs that can teach each of these skills in a safe, learner-centric manner. It is hoped that new approaches to surgical skills training are designed in light of our understanding of educational theory to optimize the training of the next generation of plastic surgeons.

Wound drainage following groin dissection for malignant disease in adults.

BACKGROUND: Groin dissection is commonly performed for the treatment of a variety of cancers, including melanoma, and squamous cell carcinoma of the skin, penis or vulva. It is uncertain whether insertion of a drain reduces complication rates, and, if used, the optimum time for drain removal after surgery is also unknown. OBJECTIVES: To assess the current level of evidence to determine whether placement of a drain is beneficial after groin dissection in terms of reducing seroma, haematoma, wound dehiscence and wound infection rates, and to determine the optimal type and duration of drainage following groin dissection if it is shown to be beneficial. SEARCH METHODS: In September 2014 we searched the following electronic databases using a pre-designed search strategy: the Cochrane Wounds Group Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library). In November 2013 we searched Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE and EBSCO CINAHL. We did not restrict the search and study selection with respect to language, date of publication or study setting. SELECTION CRITERIA: We considered all randomised controlled trials (RCTs) comparing wound drainage with no wound drainage in individuals undergoing groin dissection, where the most superior node excised was Cloquet's node (the most superior inguinal lymph node). No limits were applied to language of publication or trial location. Two review authors independently determined the eligibility of each trial. DATA COLLECTION AND ANALYSIS: Two review authors, working independently, screened studies identified from the search; there were no disagreements. MAIN RESULTS: We did not identify any RCTs that met the inclusion criteria for the review. AUTHORS' CONCLUSIONS: There is a need for high quality RCTs to guide clinical practice in this under-researched area.

Surgical skills training: time to start early.

BACKGROUND: Changes in undergraduate medical curricula, combined with reforms in postgraduate education, have training implications for surgical skills acquisition in a climate of reduced clinical exposure. Confidence and prior experience influences the educational impact of learning. Currently there are limited formal basic surgical skills programmes integrated into UK undergraduate curricula. CONTEXT: Early skills targeting is valuable for students entering surgical, related allied specialties and even traditionally non-surgical specialties, such as General Practice. Such experience can make students more confident and subsequently competent future junior doctors and trainees. INNOVATION: The integration of skills training through the use of simple low-fidelity training models can bridge the gap between undergraduate skills education and postgraduate training, whereas approaches involving more recent advances in simulation may prepare students further by making available more contextualised and scenario-based learning environments. IMPLICATIONS: We suggest that it is an ideal time for the introduction of dedicated basic surgical skills programmes into UK undergraduate medical curricula. Training will benefit all students. Importantly, training can inspire confidence, clinical interest, and can also provide a solid foundation of skills that can support and enable junior doctors' further postgraduate training.

Handover practice amongst core surgical trainees at the Oxford School of Surgery.

PURPOSE: To date no studies have specifically evaluated the use of handovers amongst core surgical trainees (CSTs) in the United Kingdom. We examined handover practice at the Oxford School of Surgery to assess and improve CSTs'perception of handover use as well as its quality, and ultimately patient care. METHODS: Based on guidelines published by the British Medical Association and Royal College of Surgeons, a 5-point Likert style questionnaire that collected data on handover practice, its educational value, and the CSTs'satisfaction with handover was given to 50 CSTs in 2010. RESULTS: Forty CSTs (80.0%) responded to the questionnaire. The most striking findings revolved around the perceived educational value, formal training, and auditing practice of handovers throughout various units, which were all remarkably lower than expected. As a result, handover practice amongst CSTs was targeted and revised at the University Hospital's Department of Plastic Surgery, with the implementation of targeted changes to improve handover practice. CONCLUSION: The execution of daily handovers was an underused educational tool amongst surveyed CSTs and may be an important modality to target, particularly in the competency-based, time-limited training CSTs receive. We recommend modifications to current practice based on our results and the literature and encourage the assessment of handover practice at other institutions.

Proposing "the burns suite" as a novel simulation tool for advancing the delivery of burns education.

Educational theory highlights the importance of contextualized simulation for effective learning. We explored this concept in a burns scenario in a novel, low-cost, high-fidelity, portable, immersive simulation environment (referred to as distributed simulation). This contextualized simulation/distributed simulation combination was named "The Burns Suite" (TBS). A pediatric burn resuscitation scenario was selected after high trainee demand. It was designed on Advanced Trauma and Life Support and Emergency Management of Severe Burns principles and refined using expert opinion through cognitive task analysis. TBS contained "realism" props, briefed nurses, and a simulated patient. Novices and experts were recruited. Five-point Likert-type questionnaires were developed for face and content validity. Cronbach's α was calculated for scale reliability. Semistructured interviews captured responses for qualitative thematic analysis allowing for data triangulation. Twelve participants completed TBS scenario. Mean face and content validity ratings were high (4.6 and 4.5, respectively; range, 4-5). The internal consistency of questions was high. Qualitative data analysis revealed that participants felt 1) the experience was "real" and they were "able to behave as if in a real resuscitation environment," and 2) TBS "addressed what Advanced Trauma and Life Support and Emergency Management of Severe Burns didn't" (including the efficacy of incorporating nontechnical skills). TBS provides a novel, effective simulation tool to significantly advance the delivery of burns education. Recreating clinical challenge is crucial to optimize simulation training. This low-cost approach also has major implications for surgical education, particularly during increasing financial austerity. Alternative scenarios and/or procedures can be recreated within TBS, providing a diverse educational immersive simulation experience.

Wound drainage after axillary dissection for carcinoma of the breast.

BACKGROUND: Axillary dissection is commonly performed for breast carcinoma. It is uncertain whether insertion of a drain reduces complication rates. OBJECTIVES: To assess the effects of wound drainage after axillary dissection for breast carcinoma on the incidence of postoperative seroma formation. Secondary outcome measures include the incidence of infection and length of hospital stay. SEARCH METHODS: We searched the Cochrane Wound and Breast Cancer Group's Specialised Registers (22 February 2013), MEDLINE (1950 to 22 February 2013), EMBASE (1966 to 22 February 2013), the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) and ClinicalTrials.gov (22 February 2013) for all prospectively registered and ongoing trials (22 February 2013). Reference lists of included studies were handsearched by two independent review authors to look for additional eligible trials. SELECTION CRITERIA: All randomised controlled trials (RCTs) comparing wound drainage versus no wound drainage in individuals after axillary dissection for the treatment of breast carcinoma were included. All disease stages were considered. Breast-conserving surgery and mastectomy were considered. Patients undergoing sentinel node biopsy without axillary dissection were not included. No limits were applied to language or study location. Two review authors independently determined the eligibility of each study. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data for each included study using a predesigned data extraction proforma and assessed risk of bias using The Cochrane Collaboration's 'Risk of bias' tool. Discrepancies were resolved by consensus discussion with a third review author. Dichotomous variables were analysed using a Mantel-Haenszel model to produce odds ratios (ORs). Continuous variables were analysed using an inverse variance model to produce a mean difference (MD). MAIN RESULTS: Seven RCTs including 960 participants were identified. The quality of trials was generally low, with several studies at risk of selection bias, and no studies used blinding during treatment or outcome assessment. There was a high level of statistical variation between the studies, which therefore reduces the reliability of the evidence. The OR for seroma formation was 0.46 (95% confidence interval (CI) 0.23 to 0.91, P = 0.03) in favour of a reduced incidence of seroma in participants with drains inserted. There was no significant difference in infection rates between drainage and no drainage groups (OR = 0.70; 95% CI 0.44 to 1.12, P = 0.14). The mean difference in length of hospital stay, reported in four trials consisting of 600 participants, was 1.47 days greater in the drained population (95% CI 0.67 to 2.28, P = 0.0003). A mean difference of 0.79 fewer postoperative seroma aspirations was found in the drained population (95% CI 1.23 to 0.35 fewer, P = 0.0004) in two trials including 212 participants. No significant difference in volume of seroma aspirations was reported (MD -19.44, 95% CI -59.45 to 20.57, P = 0.34) in three trials including 519 participants. No significant difference in the incidence of lymphoedema was noted (OR 2.31 favouring no drainage, 95% CI 0.47 to 11.37, P = 0.30), with only six instances reported in three trials of 360 participants, nor was any significant difference in the incidence of haematoma observed (OR 1.68, 95% CI 0.33 to 8.51, P = 0.53), with only five instances reported in two trials of 314 participants. AUTHORS' CONCLUSIONS: There is limited quality evidence that insertion of a drain following axillary lymphadenectomy reduced the odds of developing a seroma and reduced the number of post-operative seroma aspirations. These benefits should be balanced against an increased length of hospital stay in the drained population.

Surgical experts: born or made?

The concept of surgical expertise and the processes involved in its development are topical, and there is a constant drive to identify reliable measures of expert performance in surgery. This review explores the notion of whether surgical experts are "born" or "made", with reference to educational theory and pertinent literature. Peer-reviewed publications, books, and online resources on surgical education, expertise and training were reviewed. Important themes and aspects of expertise acquisition were identified in order to better understand the concept of a surgical expert. The definition of surgical expertise and several important aspects of its development are highlighted. Innate talent plays an important role, but is insufficient on its own to produce a surgical expert. Multiple theories that explore motor skill acquisition and memory are relevant, and Ericsson's theory of the development of competence followed by deliberate self-practice has been especially influential. Psychomotor and non-technical skills are necessary for progression in the current climate in light of our training curricula; surgical experts are adaptive experts who excel in these. The literature suggests that surgical expertise is reached through practice; surgical experts are made, not born. A deeper understanding of the nature of expert performance and its development will ensure that surgical education training programmes are of the highest possible quality. Surgical educators should aim to develop an expertise-based approach, with expert performance as the benchmark.

Simulators and the simulation environment: getting the balance right in simulation-based surgical education.

INTRODUCTION: Simulation occupies a central position in surgical education. It offers a safe environment for trainees to develop and improve their skills through sustained deliberate self-practice and appropriate feedback. This review explores the role of simulators and the simulation environment in light of educational theory to promote effective learning. DATA SOURCES: Information was obtained from peer-reviewed publications, books and online material. CONCLUSION: A simplistic perspective frames simulation as a means of gaining technical skills on basic models by offering a safe alternative to carrying out procedures on real patients. Although necessary, that aspect of simulation requires greater depth to satisfy the growing demand for alternatives to traditional clinical learning. A more realistic view should frame simulation as a means to gaining mastery within a complex clinical world. In order to strike the balance on simulating an ideal clinical scenario, alignment of the simulator and the simulation environment in the appropriate context appears crucial.

Practical skills teaching in contemporary surgical education: how can educational theory be applied to promote effective learning?

BACKGROUND: Teaching practical skills is a core component of undergraduate and postgraduate surgical education. It is crucial to optimize our current learning and teaching models, particularly in a climate of decreased clinical exposure. This review explores the role of educational theory in promoting effective learning in practical skills teaching. METHODS: Peer-reviewed publications, books, and online resources from national bodies (eg, the UK General Medical Council) were reviewed. RESULTS: This review highlights several aspects of surgical education, modeling them on current educational theory. These include the following: (1) acquisition and retention of motor skills (Miller's triangle; Fitts' and Posner's theory), (2) development of expertise after repeated practice and regular reinforcement (Ericsson's theory), (3) importance of the availability of expert assistance (Vygotsky's theory), (4) learning within communities of practice (Lave and Wenger's theory), (5) importance of feedback in learning practical skills (Boud, Schon, and Endes' theories), and (6) affective component of learning. CONCLUSIONS: It is hoped that new approaches to practical skills teaching are designed in light of our understanding of educational theory.

Total parathyroidectomy without autotransplantation after renal transplantation for tertiary hyperparathyroidism: long-term follow-up.

INTRODUCTION: Renal transplant patients are unique in that bone changes occur on a background of pre-existing chronic kidney disease-mineral bone disorder. In a few cases, there is overt hyperparathyroidism manifested by hypercalcaemia. Traditionally, if severe or persistent, this is treated by parathyroidectomy. At our unit, the default surgical operation is total parathyroidectomy without autotransplantation. METHODS: Patient charts for the last three decades were reviewed retrospectively. Twenty-six subjects with functioning renal transplants who underwent parathyroidectomy had biochemistry and clinical information for at least 6 months pre- and post-surgery. The criteria for parathyroidectomy were persistent hypercalcaemia (>2.75 mmol/L) and/or clinical problems (e.g. kidney stones). A 5-year follow-up was available for all 26 subjects and a 9-year follow-up for 20 patients. RESULTS: After surgery, patients were supplemented with 1-α-calcidol. The median preoperative calcium level was 3.10 mmol/L. One month postoperatively, this fell to 2.41 mmol/L. Normocalcaemia was maintained at 5 years (2.40 mmol/L) and at 9 years (2.39 mmol/L), with a calcium-phosphate product of 3.0 mmol(2)/L(2) and median parathyroid hormone level of 12 pg/mL. CONCLUSION: Total parathyroidectomy without autotransplantation in renal transplant patients appears to be protective against persistent and recurrent disease. This is the largest series with the longest follow-up available in the literature of this specific patient population.

Educating surgical patients to reduce the risk of venous thromboembolism: an audit of an effective strategy.

OBJECTIVES: Venous thromboembolism (VTE) causes approximately 25,000 deaths each year from hospital-acquired thrombosis in the UK. Patient understanding of risk factors and preventive measures is important in preventing VTE. This audit was designed to assess surgical patient awareness and understanding of VTE risk factors and prophylaxis. DESIGN: A questionnaire was designed to assess preoperative patient understanding of components of the National Institute for Health and Clinical Excellence (NICE) guidelines. Leaflets were designed to address gaps in understanding and junior doctors were given guidance on patient education. A second group of patients completed the same questionnaire after introduction of the education system. SETTING: Worthing Hospital, UK. PARTICIPANTS: One hundred and twenty-one patients due to undergo major general surgery. Seventy-one participants completed the questionnaire prior to implementation of the education system, and 50 after. MAIN OUTCOME MEASURES: Improvement in patient awareness of VTE, its risk factors and its preventative measures (in response to the education system). RESULTS: Following the introduction of a targeted VTE education system, there was a significant improvement in the awareness of VTE to 90% (P < 0.01), its signs to 80% (P < 0.01), and its preventative measures to 84% (P < 0.01). CONCLUSIONS: Patient education is of paramount importance in reducing the risks of VTE perioperatively. A simple method of introducing patient education at pre-assessment clinic and as part of their discharge planning, for major elective surgery, is an effective system in improving patient understanding of VTE, its risk factors and the importance of prophylaxis. It may also increase compliance.

Tuberculosis complicating tertiary hyperparathyroidism in a patient with end-stage renal disease: a case report.

A 36-year-old Nigerian woman on thrice-weekly dialysis presented with symptoms and signs of hypercalcaemia. Laboratory findings were consistent with tertiary hyperparathyroidism. Parathyroid hormone levels remained elevated and she underwent elective parathyroidectomy. Intra-operatively all 4 parathyroid glands and local lymph nodes showed necrotising granulomas with occasional acid-fast bacilli, pathognomonic of tuberculosis (TB). Post-operatively she completed a full course of anti-TB therapy and at 9 months she experienced complete resolution in her plasma biochemistry and was essentially symptom-free. This is a rare yet fascinating cause of hypercalcaemia in a dialysis patient and is the first recorded case of tubercular involvement of parathyroid tissue in a case of tertiary hyperparathyroidism. This report demonstrates the coexistence of 2 diseases that simultaneously worsened hypercalcaemia and thus emphasises the importance of the differential diagnosis and of careful histological examination post-operation.